Anaesthetic practitioners in the UK: promise, perils and psychology

Anaesthesia is administered by non-physician practitioners in many countries of the world. Although the Association of Anaesthetists of Great Britain and Ireland and the Royal College of Anaesthetists have in the past argued against the introduction of such a role into the United Kingdom [1], circumstances have changed and both organisations have engaged with the Changing Workforce Programme's ‘New Ways of Working in Anaesthetics’ project. However, this remains controversial amongst the anaesthetic community at large. In this editorial, rather than argue for or against this development, I want to try to straighten out some crooked thinking that clouds this issue and set it in context. A number of possible benefits have been suggested for the introduction of anaesthetic practitioners (APs) into the United Kingdom anaesthesia workforce. First and most importantly, they may help anaesthetic departments meet European Working Time Directive (EWTD) targets for both trainees and permanent staff alike. Second, their presence may enable improved training for medical postgraduate anaesthetic trainees. Third, the role may provide career development for existing operating theatre staff. Fourth, they may allow more flexible deployment of anaesthetic staff. Another possible benefit usually included in such lists by advocates of National Health Service (NHS) modernisation is ‘improving the patient experience’[2]. However, my view is that the phrase has been hijacked and subverted by so many different professional and managerial interests, each claiming to have its own understanding of what the patient's experience may be, that it is virtually meaningless. Another favourite is ‘improving working lives’ for those in the NHS [3]. The fact that morale amongst many staff would be improved considerably by simply removing short-term political interference and allowing them to get on with the jobs they trained for suggests to me that confusion and muddle have become so commonplace in Department of Health policy-making that it seldom arouses comment when two or more policies are mutually contradictory or conflicting. This has, however, been noted by Sir Kenneth Calman and colleagues at the School for Health at the University of Durham, who argue that the very implementation of the NHS Plan is endangered by constant policy change, regulation, inspection and lack of meaningful public involvement [4]. There are also many possible objections to the introduction of anaesthetic practitioners. I will address some of these in turn. This is perhaps the most commonly heard objection amongst anaesthetists. This is not in itself surprising; right from the very start of our training in anaesthesia, we learn to think in terms of risk and safety. These concepts are so well embedded in the anaesthetic psyche that the rest of the world almost comes to be viewed through this particular lens. Thus the unease that many anaesthetists feel at the prospect of the non-physician practitioner tends to be expressed in these terms instead of any other [5, 6]. We were funded by the NHS Service Delivery and Organisation Research and Development Programme (SDO) both to review the published scientific literature on this issue and to explore possible barriers to, and enablers of, the introduction of APs into the United Kingdom. We found only four reports of primary research addressing the question of whether there was a difference in safety or effectiveness between physician and non-physician anaesthetists [7]. None of these was a randomised comparison, and all had methodological flaws. The first was a large, carefully conducted study of untoward incidents during anaesthesia in a number of Danish hospitals [8]. No significant differences in incident rates between trained physician anaesthetists and experienced nurse anaesthetists were found. Trainee practitioners from both professions had a higher rate of incidents. The paper by Silber et al. [9] reported a retrospective analysis of a large data set of financial and administrative data from patients undergoing surgical procedures in Pennsylvania, USA, between 1991 and 1994. The overall odds ratio for death and ‘failure to rescue’ (a measure of how successfully complications were dealt with when they occurred) favoured anaesthesia directed by physicians. However, the difference was small and many of the complications included could not be attributed directly to anaesthesia. The third study was a small, well-circumscribed investigation of minor adverse incidents during ENT surgery. No differences were noted in complication rates between the different providers [10]. The analysis by Pine and colleagues was similar to Silber et al.'s in that it drew its data from large administrative datasets [11]. The authors found no difference in overall surgical mortality with the type of anaesthetic provider, although complications related to anaesthesia were not separated out. Our interpretation of these studies was that there was no consistent high level evidence for a difference in safety between physician and non-physician anaesthetists [7]. Furthermore, it is extremely unlikely that any such evidence would ever be generated. Opponents of non-physician anaesthesia sometimes suggest deferring their introduction until their merits have been investigated in a suitably powered randomised controlled trial. However, not only would such a trial have to be very large in view of the relative scarcity of serious adverse events attributable to anaesthesia, it would also be unethical. It would simply not be possible to randomise patients to care provided by one type of practitioner or another, as this is significantly different from the current practice of matching anaesthetic skills to the patient's condition and surgical demand. This lack of supporting evidence is sometimes played as a ‘trump card’ to justify the status quo. Such concerns over evidence have not, however, prevented the introduction of many practices, techniques and devices into anaesthesia in the past. One further publication worthy of mention is that of Abenstein and Warner from 1996 [12]. This presents the authors' interpretation of a number of older studies of anaesthetic outcome and concludes that the ‘anaesthesiologist-led anaesthesia care team’ provides the safest anaesthesia care. Whilst this conclusion may be correct (possible variations in meaning of the ‘anaesthesia care team’ notwithstanding), it is not the only interpretation of the data presented. What the article does reveal is something of the tensions between nurse anaesthetists and anaesthesiologists in the United States at the time it was written. However, as it appeared in a prestigious journal (albeit accompanied by a qualifying editorial [13]) and its message seemed to find favour with US anaesthesiologists at the time, it has since been widely quoted and appears to have taken on the status of primary authoritative evidence. It is not. This objection appears to stem from an incomplete understanding of the relationship between anaesthesiologists and nurse anaesthetists in the United States of America. As this seemed relevant to our work for the SDO, we traced the history and development of professional relationships in the United States [14]. The commonly held view amongst UK anaesthetists appears to be that American nurse anaesthetists, like Frankenstein's monster, took on an independent life of their own and then set about destroying their creator. This is inaccurate. Anaesthesia in the United States began as a nursing speciality. Throughout the 1930s, and particularly after the Second World War, an increasing number of physicians joined them, and the American Society of Anesthesiologists succeeded in having the specialty of anaesthesiology recognised as one aspect of the practice of medicine. The number of both anaesthesiologists and nurse anaesthetists continued to increase. President Johnson's healthcare reforms in the 1960s allowed anaesthesiologists to submit bills to Medicare (the main state insurer) for supervising a number of nurse anaesthetists simultaneously. These changes made anaesthesiology a lucrative speciality, but subsequent changes to the payment system in the 1980s and early 1990s removed this advantage. In many states, nurse anaesthetists campaigned for, and succeeded in getting, independent practice rights. Anaesthesiologists campaigned to restrict this loss of income. Whilst interprofessional relations were usually excellent at an individual level, there was considerable tension between the professional organisations. Only in the last 18 months or so have moves towards reconciliation been made. Given the difference in practice and payment arrangements between the United Kingdom and the United States, and the fact that the Royal College of Anaesthetists is firmly in control of the training of UK anaesthetic practitioners, it is unlikely that this situation would be replicated on this side of the Atlantic. Mention of the words ‘nurse anaesthetist’ seems to bring about reflex overstimulation of the sympathetic nervous system in UK anaesthetists but I hope that a fuller appreciation of the American experience will act as collective ‘cognitive behaviour therapy’ for the anaesthetic community in this respect. There are two aspects to inflexibility, although it is not always clear which is being objected to. The first is that anaesthetic practitioners may only be able to anaesthetise certain types of patient. Anaesthesia for cardiac surgery, neurosurgery, other complex major cases or young children, for instance, might not be within their remit, although it must be remembered that APs – as the role is currently envisaged – will not be practising independently. Whilst there may be quality of care issues here, there may be an element of professional protectionism, too. However, if the scope of the anaesthetic practitioner's work is restricted for political rather than practical reasons, we cannot then complain that they are not allowed to work more widely. It is illogical for the same characteristic to be both a desirable feature of the role and at the same time an objection to it. The second aspect to inflexibility is how practitioners think about their work. In other areas of health care, practice is usually protocolised when it is divested from doctors to others (usually nurses). Many anaesthetists have concerns that this approach is less applicable to anaesthesia, with its more fluid and uncertain style of practice. Our own work on expertise in anaesthesia [15] has suggested that experts have not only a greater textbook knowledge, but also a larger repertoire of techniques and the skill to know when things are not going according to plan and how to rectify the situation. Anaesthetists are unlikely to be reassured by a practitioner who lacks this mental flexibility and responsiveness. However, whether this is a function of professional background, style of training or clinical experience is something that until now we have not been able to determine in the United Kingdom. It will be interesting to see how anaesthetic practitioners develop as they gain experience and confidence. This objection is valid. Any anaesthetic department will have finite training resources, and if some of these are used in training anaesthetic practitioners, fewer will be available for postgraduate medical trainees. This is being addressed in the current proposals for training practitioners. A maximum of two would be trained at any one time in any one hospital. This is certainly true. The operating theatre is a complex system. Changing one aspect will inevitably necessitate, and lead to, changes in other aspects. It may be necessary to change the way other theatre staff work and how anaesthetic departments are structured, organised and deployed. It will be quite a change for UK consultants to spend most of their time supervising others giving anaesthetics and the effect on workload and style of practice is yet unknown. It may be necessary also for anaesthetists to wrest the responsibility for constructing operating lists and scheduling theatres from the surgeons in order to maximise deployment of anaesthetic staff. Ultimately, too, operating theatre design may play its part in how anaesthetic services are delivered, as larger centralised suites may make it easier for consultants to supervise practitioners and work more flexibly in sharing this duty between adjoining theatres. As we had two Swiss nurse anaesthetists working in Lancaster for a year as part of the New Ways of Working project, I can also add some of our practical experiences to the comments above. Many of the problems we faced were related to the fact that our practitioners were from overseas and included recruitment, adaptation/orientation, settling in, language and practicalities of living in an unfamiliar country. It would certainly be unrealistic to expect practitioners to arrive one day and be taking an active part in the rota the next. (These are likely to be less relevant in that most of the hospitals taking part in the second phase of the programme are intending to train UK theatre staff or science graduates). The theatre staff took well to the new role, or rather to the two individuals who occupy it in Lancaster. The consultant anaesthetists – without whom the project could not have been run – were broadly in favour of taking part in the ‘experiment’, but remain ambivalent about continuing with this model of practice locally. One of our main difficulties was working out where to pitch our expectations of the APs' knowledge and skills. They are clearly more than operating department practitioners (ODPs), in that their role includes many things ODPs do not do. They also could not be compared with anaesthetic senior house officers (SHOs), as SHOs, although inexperienced, are expected to develop into clinicians with a wide range of independent capabilities. Some of the other problems we encountered look set to be addressed at a national level in due course. For instance, the anaesthetic practitioner role may well become a separate, legally recognised profession within the existing Allied Health Professions umbrella, with the Royal College of Anaesthetists overseeing the clinical anaesthetic standards in some way. Independent prescribing by non-physicians is also being developed nationally, albeit rather slowly. There were benefits, of course. Anaesthetic practitioners working in the operating theatre can go to the wards to perform pre-operative assessment or can prepare patients and drugs in the anaesthetic room. Consultants can safely leave practitioners in charge of anaesthetised patients to go to the telephone, deal with e-mails, attend to other patients or supervise/teach trainees. We demonstrated that a two-to-one practitioner-to-consultant ratio is feasible, and were able to use our practitioners to help avoid last-minute cancellations due to staff sickness. However, as trainee rotas at the Royal Lancaster Infirmary were already EWTD compliant, we were not able to demonstrate an improvement in this regard. It is self-evident that the more future anaesthetic practitioners can do independently, the more useful they will be as part of the anaesthetic workforce. It is clearly quite feasible to incorporate anaesthetic practitioners into a UK department, although in the longer term a number of wider issues must be addressed, including the deployment of anaesthetic staffing, extent of protocolisation of anaesthetic work, how operating lists are put together and how theatres are designed, built and staffed. The anaesthetic practitioner model generally works well overseas and there is no good evidence one way or the other as to the relative safety of nurse or physician anaesthetists. In such an ‘evidence-free zone’, the future is decided, rightly, by the anaesthetic community based on what is considered desirable and necessary rather than simply what is possible. However, one of the biggest obstacles to the introduction of anaesthetic practitioners is less clearly and less often expressed, but no less real. The impression of constant politically driven change and upheaval in the NHS is both dispiriting and demoralising for clinical staff. It also makes them more timid and wary of novelty. The success of most ‘modernisation’ initiatives depends on the continuing good will and support of staff. Whilst many do not actively resist change, there are few who actually embrace it. People may feel as though they work in a system which they recognise as unsatisfactory for both patients and staff, but seem quite powerless to do anything to improve matters. Psychologists have termed this ‘learned helplessness’[16]. In a typical experiment, a dog is submitted to a small electric shock before being placed in a cage on a metal floor whose two halves can be electrified alternately. Initially when the current to one half of the floor is switched on, the animal leaps to the other side, then leaps back again when that side in turn is electrified. If this pattern continues, the dog eventually ceases to take avoidance behaviour, and remains on the electrified side. Whilst such animal experiments are no longer considered acceptable, we run the risk that a similar psychological state will emerge in NHS staff during the process of ‘modernisation’. The biggest threat to standards and practice in British anaesthesia may yet turn out to be not new roles and ways of working but a gradual and widespread implosion, involution and disengagement of those who work in the service in response to externally driven and thoughtlessly imposed ‘reform’. Professor Smith was the clinical lead at the Morecambe Bay Hospitals site for the Changing Workforce Programme's ‘New Ways of Working in Anaesthetics’ project, funded by the UK Department of Health. The views expressed here are his own.